How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England.

BACKGROUND: Child and Adolescent Mental Health Services (CAMHS) in England are making significant changes to improve access and effectiveness. This 'transformation' variously involves easier access to services through a Single Point of Access (SPA), more integrated services within CAMHS and enhanced co-provision across education and third sector or non-profit organisations.
METHODS: A mixed-methods observational study was conducted to explore the process and impact of transformation over four years in two services. Ethnographic observations and in-depth interviews were conducted and Electronic Patient Records with over one million contacts analysed. Difference-in-differences analysis with propensity score matching to estimate the causal impact of the transformation on patient access was utilised. OUTCOMES: Spend and staffing increased across both CAMHS. The SPA had growing rates of self-referral and new care pathways were seeing patients according to expected degree of psychopathology. Third sector partners were providing increasing numbers of low-intensity interventions. Although the majority of staff were supportive of the changes, the process of transformation led to service tensions. In the first year after transformation there was no change in the rate of new patients accessing services or new spells (episodes of care) in the services. However, by year three, the number of new patients accessing CAMHS was 19% higher (Incidence Rate Ratio: 1·19, CI: 1·16, 1·21) and the rate of new spells was 12% higher (Incidence Rate Ratio: 1·12, CI: 1·05, 1·20).
INTERPRETATION: Transformation investment, both financial and intellectual, can help to increase access to CAMHS in England, but time is needed to realise the benefits of reorganisation.

Introduction

There is heightened interest across many countries as to how mental health services can best meet the needs of their child and adolescent populations [1,2]. The rising number of young people presenting with mental health needs is propelling services, across a number of nations, to introduce broad systemic changes. Making child and adolescent mental health services (CAMHS) more accessible to young people is driving many changes taking place in England, which have been mirrored in countries including Canada, Australia, the US and Ireland [3-8]. Access to services for children and adolescents include a number of different factors, including: knowledge, attitudes, and beliefs about mental health problems and treatment held by both young people and their parents; where these services are geographically located; how they can be approached; and once approached whether they have the resources to address any identified need [9].

In England the focus on improving access to services, for those under the age of 18, has led to a major reorganization of CAMHS aligned with the THRIVE model which recommends principles by which services can be organized [10] emphasising five areas: Thriving, Getting advice and signposting, Getting Help, Getting More Help and Getting Risk Support. The focus of this model lies in making the experience of mental health services for the young person less confusing and encourages shared decision-making with the children, adolescents and their families. The new model tries to enable all the agencies that are involved in a young person’s life to work together in a coherent and integrated manner.

Government directives have therefore encouraged many CAMHS services, through commissioners, to ‘transform’ their services to improve accessibility, increase quality of care and improve health outcomes [4,11], although the pace and direction of change is determined at the local level. Therefore a natural experiment is taking place across CAMHS in England where different components of services are being changed to try and better address the identified needs of the young population and improve access to services in general. Many of the services have even adopted the THRIVE terms for the different parts of their newly ‘transformed’ services.

This observational mixed methods study aims to build on the limited evidence-base that currently exists on the impact and implementation of these system wide changes to CAMHS. We will describe components of two CAMHS services experiencing service ‘transformation’ at different time points and with some differences in how the changes are translated and evaluate their resultant changes in access to services, as measured by the actual number of children and adolescents entering the services.

Methods

Study setting

The study was conducted in CAMHS provided by Oxford Health NHS Foundation Trust (Oxford Health) (Supporting information 1: Map and Demographics of study area in S1 Appendix). Oxford Health is one of the largest CAMHS providers in England [12], delivering services for Clinical Commissioning Groups (CCGs) to NHS services in Buckinghamshire (Bucks); Oxfordshire (Oxon); and Swindon, Wiltshire, and Bath and North East Somerset (SWB). We investigated the CAMHS changes or ‘transformation’ in Bucks and Oxon. These services are commissioned locally and therefore we were able to examine the changes taking place in the different areas as described in the study protocol [13]. The changes in Bucks took place from 2015 and in Oxon from 2018 as each area made changes according to when their service agreements are being renegotiated and designed. For many services these take place on a five-year cycle and therefore depending on when these are confirmed, the new services were introduced.

Design and research methods

We followed an implementation science approach utilising mixed-methods as detailed in the study protocol [13] with the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. This framework has a particular focus on implementation of complex interventions in real-world settings [14].

This study aimed to understand the implementation of CAMHS transformation and assess its impact on access to care by addressing the following research questions:

What components are being adopted as part of the CAMHS transformation? (Adoption)

How are the transformations being implemented and maintained? (Maintenance)

What are the facilitators and barriers to transformation? (Implementation)

What is the effect of transformation on service activity / pathways? (Reach)

What is the impact of the transformation on patient access? (Effectiveness)

Qualitative data and analysis

Qualitative data collection (by MS, January 2018 to March 2019) focused on the CAMHS transformation in both Bucks and Oxon including 80 hours of ethnographic observations—shadowing key staff, informal interviews with different stakeholders and attending team meetings. Observations were determined by access to particular settings (such as the SPA and meetings) through key staff or ‘gatekeepers’. A field diary was kept throughout to record observations with particular attention paid to the RE-AIM framework. The objective was to record and observe naturally occurring interactions: watching, listening, and better understanding how transformation processes were occurring and being interpreted ‘on the ground’. The observation period for this study included both a pre- and post-transformation period. In addition, in-depth interviews with eighteen members of staff, including a range of administrative and clinical staff, service managers, team leads and those involved in the Single Point of Access (SPA), specialist pathway services and third sector (charity, social enterprises and voluntary group) partners. The questions asked were framed around the implementation questions of interest, including what they perceived as the main changes taking place in their organisations, what they thought the benefits and problems were associated with these changes and the processes by which these changes had been introduced and sustained. Interviews were also conducted with eight young people and four parents/carers (2 paired interviews) with experience of using CAMHS pre- and post-transformation. All the interviews were digitally recorded and professionally transcribed. Thematic analysis of the data followed a modified grounded theory approach using N-Vivo [15].

Quantitative data and analysis

Data from electronic patient records was available from April 2012 to March 2019, encompassing pre- and post-transformation. We also had access to all routine outcome measures (ROMs) recorded electronically over this period, including the Revised Child Depression and Anxiety Scale (RCADS) which is a well-validated and widely used measure that gives a score denoting clinical caseness. Data on whole-time equivalents and direct staff spend was available from 2013/14 to 2018/19, with whole CAMHS funding available from 2015/16.

Data was grouped into distinct spells of care (care received from admission to discharge) and analysed from October 2013 to March 2019 [16]. A quasi-experimental approach to evaluating this ‘complex’ intervention was adopted [17,18]. A difference-in-differences (DiD) framework was employed and supplemented with propensity score matching for the analysis of re-referrals and waiting times [16]. In the main analysis, Bucks was compared with Oxon. For a sensitivity analysis, both Oxon and SWB were included as the control group.

We adopted a parallel convergent mixed methods design [19]. The quantitative and qualitative data were collected concurrently and analysed separately. We then integrated the quantitative and qualitative datasets to address the research questions in the following way. Hypotheses (arising from the quantitative data) and themes (from the qualitative data), generated from the separate analyses, were explored in the light of the findings from the other dataset. In this way, key issues emerging from one of the components was then examined alongside evidence from the other component. This enabled us to obtain explanation and context around an issue, as well as prompting new questions to take back to the other dataset. This approach, known as ‘following a thread’ (described by O’Cathain et al) [20], which involves iteratively moving between quantitative and qualitative datasets, enabled us to achieve multiple perspectives on the transformation and more complete interpretation and understanding of the impacts of the reorganization.

Ethics

Anonymized routinely collected patient level data for this study was shared according to a local data sharing agreement with Oxford Health NHS Foundation Trust. This study was registered with Oxford Health NHS Foundation Trust approved by the Children and Young People’s directorate (4/4/2018). Interview participants gave informed consent for participation.

Results (including refined methods)

Components of CAMHS transformation

Bucks and Oxon had similar core components of transformation which are each reported below, namely:

a single point of access (SPA) to CAMHS with the possibility for self-referral;

new service delivery pathways and other specialist teams;

third sector partners directly commissioned to deliver services with or as part of CAMHS.

The transformations in Bucks and Oxon were aligned with the transformations taking places across England, as evidenced by reviewing a local transformation plan from each NHS region (the first alphabetically placed commissioning group) (Fig 1). The majority of plans included a SPA with the possibility of self-referral, many used the THRIVE model and all included third sector involvement.

Fig 1

Components of transformation across CAMHS in England.

Funding for transformation

The funding allocated by each commissioning group to the studied CAMHS from 2015 to 2019 is included in Supporting information 2 in S2 Appendix. As described elsewhere, we excluded inpatient spend and adjusted for the population [21]. Specifically, we estimated the target population by multiplying the population aged under 18 by the estimated prevalence of common mental disorders in that age group. Spend per head of target population increased 7% in Bucks between 2015/16 and 2018/19; in Oxon spend increased 22% over the same period.

The wider context for transformation is rising demand for CAMHS. NHS England set a performance target of 35% of the population in need being seen by CAMHS (two contacts in one year, excluding SMS and email) [11]. Performance against this target improved in both Bucks and Oxon with a steady increase to 35% in Bucks (2018/19) and in Oxon, the rate peaked at 44% in 2017/18, before falling to 41% in 2018/19 (Fig 2).

Fig 2

CAMHS budget and performance against attendance target.

SPA

For staff, the introduction of the SPA was perceived as the core change of the CAMHS transformation, with a central team based in one location taking online and telephone referrals from health, social care and education professionals, family members, as well as young people themselves. This was evident from the redesign of how the services were being managed, the staff interviews and the observations from the services. A particular innovation was the ability of parents/carers and young people to self-refer (primarily for those aged 16 and 17, but available to younger callers). This component was designed to improve accessibility and rationalise referrals.

“…anyone can access us and have a conversation as soon as they have got a question about mental health and we will listen to them and try and do something with that…For me, the biggest single change that we have managed to bring about lies in SPA.”

(Staff interview)

In both Bucks and Oxon, the numbers of people accessing SPA climbed quickly following initial awareness-raising activities [22]. While much of the emphasis on SPA was on the phone line, as the service evolved, increasing numbers of requests were received online, as described in more detail by Rocks et al [22] The introduction of the SPA was associated with an increase in self-referrals, both from carers and children and adolescents, and a fall in the proportion of referrals from primary care [22].

For some young people and families we interviewed, it was important that the SPA change was clear and that the new service provision had clarity:

“(Young person) So it’s a referral line, really? Would it do anything [..]so like if a teenager phoned up who is using it kind of like Samaritans type call, does it have that—[interviewer explains]

(Parent) It needs to be clear what it is, doesn’t do or what it isn’t at least.”

New pathways

The CAMHS transformation involved a change from a services that were separated into four different tiers to a more integrated approach to the different services. For example, the tiered approach to services had children and adolescents seen in the service tier that corresponded with their needs- with tier one services often delivering services in the community and tier three and four services for children and adolescents with more severe or complex mental health difficulties likely needing a multidisciplinary and more specialized approach. These were changed in the THRIVE model to ‘pathways’ [10,23] called ‘Getting Help’ and ‘Getting More Help’, where the young person would try and be seen for all their needs within that team and then with additional specialty teams in the services, for example for children and adolescents with eating disorders and neurodevelopmental conditions.

Fig 3 compares the breakdown of activity across the new pathways from Electronic Patient Record (EPR) data alongside the staffing mix in terms of whole time-equivalents. Prior to transformation, the majority of CAMHS contacts were in tiers 2 (Bucks 32%; Oxon 23%) and tiers 3 (Bucks 45%, Oxon 42%) (with tier 3 providing services for cases with greater complexity). Following the introduction of the new CAMHS pathways, 21% (Bucks) and 23% (Oxon) of patients were seen in ‘Getting Help’ and 26% (Bucks) and 24% (Oxon) in ‘Getting More Help’.

Fig 3

Proportion of patients seen by team and their whole-time equivalents.

“As the service has become more accessible the amount of referrals and the amount of work coming in for [Getting Help] has just mushroomed.”

(Staff interview)

The number of contacts per spell for each pathway suggests Getting Help and Getting More Help are used appropriately, with more intensive support from the latter (S3(i) Appendix). The initial severity of patients measured by the RCADS was higher among those first entering Getting More Help than Getting Help (S3(ii) Appendix).

Third sector partnerships and improved working with education

In Bucks, third sector involvement was primarily with Barnardo’s, one of the largest charities providing care to children in England. The Barnardo’s workers were placed into SPA as Contact Support Workers (CSW) where they would take initial calls and liaise with clinicians about referral decisions; and into the Getting Help pathway as ‘Buddies’ providing low-intensity interventions (S3(i) Appendix). The Getting Help pathway had seen almost 4,400 unique patients–the most of any pathway—and delivered more than 34,000 contacts (appointments) between 2015/16 to 2018/19. Staff perceived that demand for this pathway had grown. However, there was tension between being able to meet the perceived needs of an individual and the pressure to see others waiting for care as the numbers trying to access the service increased.

In Oxon, ‘Community InReach’ was established to enable CAMHS to work more closely with eight third sector partner organisations to provide alternative and supplementary support for young people.

“…a lot of those charities naturally engage with a group that we have always struggled to engage with.”

(Staff interview)

These third sector partnerships had only become fully operational at the end of the study period.

In Oxon, mental health staff provide an ‘InReach’ service to secondary schools offering advice, support and training with an emphasis was on giving school staff and students specific tools to respond to mental health problems, such as symptoms of anxiety, through training, workshops, assemblies and group work.

What are the facilitators and barriers to transformation?

Facilitators

Shared vision for transformation. The majority of staff in both services who were interviewed were positive about the vision for CAMHS transformation.

“My instinct was, it was the right model with the right language with good principles and good thinking behind it and some evidence.”

(Staff interview)

In part, this reflects perceived difficulties with the previous model of CAMHS and a recognition that change was needed:

“…it was on its knees. I think, anyway.

(Staff Interview)”

Staff in both services also felt the overall direction of the respective transformations were contributing to the development of a better service. Staff saw SPA as a way of ensuring that those children and adolescents coming into CAMHS really needed specialist help, but that others who did not, still received support and guidance.

Staff commitment. Staff showed determination to deliver services aligned with the new vision for transformation, and although there were many changes that they had to manage, many described support for the overall programme of work:

“My instinct was, it was the right model with the right language with good principles and good thinking behind it and some evidence”

(Staff Interview).

They agreed with the overall vision:

“I think it’s creative. I think it’s much more kind of proactive…there is a lot more emphasis on trying to work in the community and the proactive kind of looking at the early signs to really try and support our colleagues…in more preventative type kind of measures.”

(Staff Interview)

Furthermore, staff demonstrated their commitment to the SPA with statements such as:

“it’s just much more of a friendly front door to the service.

(Staff Interview)

“…you can ring in at any time and you can just be reopened. You don’t need a letter. You don’t need a form. You don’t need anybody else to do it for you. I think that’s a big plus.”

(Staff Interview) [22]

“We are meant to do two days a week in SPA, but because we’ve had so many calls…If somebody else is on it and I know they’re inundated, I’ll say ’I’ll do some of them’…And definitely probably work an extra hour at least each day, and don’t take a lunch.”

(Staff interview) [22]

Barriers

Destabilising a strained system. For many of the staff in both services, the CAMHS transformation was perceived as initially destabilising, with staff shifting into new posts or waiting to hear about their new roles or contract renewal, while other staff left the service. In both services, the transformation took place in less than 6 months with many staff not feeling they fully understood what would be happening. Some staff reported initial difficulties, working both within the new and old system. Across the CAMHS transformations, many of the staff felt that the implementation of the changes had been impeded by overall lack of staff. CAMHS had an increased reliance on agency staff (Fig 3), which was, however, less pronounced within the third sector partners. A key finding from the interviews with young people and parents was the perceived lack of staff consistency in CAMHS.

One of the reasons why my mum thought I relapsed again was because I had so many different people in my care at CAMHS. There was none of that consistency. Obviously, I understand that people had to move on. There was never a consistent person that wanted, well it felt to me like they wanted to help me.

(Interview, young person)

Challenges around third sector involvement. Third sector involvement in CAMHS was new and brought challenges, including agreeing standard operating procedures, creating information governance systems, defining roles, and building familiarity. In Bucks, at the start of the transformation there were comments that there were ‘differences in organisational and working culture’ between the organisations.

“the call handlers were [third sector] staff. They had just come into mental health and into the health service. So for them it was working under the NHS…So the process, the governance, the previous experiences would be very different. So for them, it was a big leap into this massive organisation”

(Staff interview)

Effect of transformation on service activity

Bucks, which transformed in 2015/16, was compared with both Oxon and SWB (as controls), which did not transform until 2018/19. Table 1(A) provides the results by year following transformation. Relative to the control services, in Bucks one year after the transformation there was no significant difference in the rate of new spells (Incidence Rate Ratio: 1.17, CI: 0.95, 1.44) or new patients (Incidence Rate Ratio: 1.17, CI: 0.95, 1.44) accessing the service. Performance improved relative to the control services in subsequent years. There were significant increases in both in years 2 and 3. By year 3, the rate of spells was 19% (Incidence Rate Ratio: 1.19, CI: 1.16, 1.21) and new patients 12% higher (Incidence Rate Ratio: 1.12, CI: 1.05, 1.20). The re-referral rate–those referred back into the service at least one month after discharge–in Bucks was not significantly different from the control services in any of the three years (S3(iii) Appendix).

Table 1

Impact of CAMHS transformation in Bucks-main & sensitivity analysis.

Panel A: Main analysis-Buckinghamshire vs. Oxfordshire and SWB
	Rate of new spells per month (per 1,000 under 18)	Rate of new patients per month (per 1,000 under 18)	Likelihood patient already seen (previous spell)	Waiting time for first contact	Waiting time for second contact
Year 1
DiD, 95% CI,	1.17 [0.95,1.44]	1.17 [0.96,1.44]	1.02 [0.88,1.19]	1.13*** [1.05,1.21]	1.02 [0.93,1.12]
SE	(0.12)	(0.12)	(0.07)	(0.04)	(0.05)
Year 2
DiD, 95% CI,	1.20*** [1.13,1.27]	1.12** [1.08,1.16]	1.02 [0.88,1.18]	1.06 [0.98,1.14]	1.12* [1.03,1.23]
SE	(0.04)	(0.02)	(0.07)	(0.04)	(0.05)
Year 3
DiD, 95% CI,	1.19*** [1.16,1.21]	1.12*** [1.05,1.20]	1.11 [0.97,1.28]	0.79*** [0.73,0.85]	0.96 [0.88,1.06]
SE	(0.01)	(0.04)	(0.08)	(0.03)	(0.04)
Observations	162	162	40757	38064	31541
Family	Poisson	Poisson	Binomial	Poisson	Poisson
Link	Log	Log	Logit	Log	Log
Panel B: Sensitivity Analysis-Buckinghamshire vs. Oxfordshire
	Rate of new spells per month (per 1,000 under 18)	Rate of new patients per month (per 1,000 under 18)	Likelihood patient already seen (previous spell)	Waiting time for first contact	Waiting time for second contact
Year 1
DiD, 95% CI,	0.93 [0.81,1.06]	0.93 [0.83,1.06]	1.01 [0.86,1.20]	1.12** [1.04,1.20]	1.03 [0.92,1.14]
SE	(0.06)	(0.06)	(0.09)	(0.04)	(0.06)
Year 2
DiD, 95% CI,	1.08 [1.00,1.17]	1.01 [0.92,1.11]	1.02 [0.87,1.20]	1.01 [0.93,1.09]	1.12* [1.01,1.24]
SE	(0.04)	(0.05)	(0.08)	(0.04)	(0.06)
Year 3
DiD, 95% CI,	1.09*** [1.07,1.12]	1.08*** [1.06,1.10]	1.04 [0.89,1.22]	0.69*** [0.64,0.75]	0.95 [0.85,1.04]
SE	(0.01)	(0.01)	(0.08)	(0.03)	(0.05)
Observations	108	108	27456	25273	21652
Family	Poisson	Poisson	Binomial	Poisson	Poisson
Link	Log	Log	Logit	Log	Log

***p-value<0.001,

**p-value<0.05, and

*p-value<0.01

DiD: Difference-in-Differences estimation.

Examining Waiting times, in year 1, there was a relative increase in waiting time for the first contact of 13% (Incidence Rate Ratio: 1.13, CI: 1.05, 1.21) compared to the pre-transformation period. By year 3, waiting times for the first contact were 21% lower (Incidence Rate Ratio: 0.79, CI: 0.73, 0.85). There was no significant difference in waiting time for the second contact in year 1 (Incidence Rate Ratio: 1.02, CI: 0.93, 1.12) or year 3 (Incidence Rate Ratio: 0.96, CI: 0.88, 1.06), but this increased in year 2 (Incidence Rate Ratio: 1.12, CI: 1.03, 1.23) (S3(iv) Appendix).

Sensitivity analysis

In the sensitivity analysis, Bucks, which transformed in 2015/16, was compared with Oxon alone, which did not transform until 2018/19. Table 1(B) provides the results by year following transformation, which support the primary analysis.

Discussion

Broad system changes are taking place across child and adolescent mental health services in the UK and this study describes a methodology for how to evaluate changing CAMHS services with a focus on access to services. Both services had increased financial investment and with the new referral pathways, increasing numbers of patients were contacting the SPA directly with an increase in 19% of new patients accessing the service by year three. The impact of the changes in Oxon and Bucks on improving access to mental health services were not immediately evident but became more apparent over time, consistent with research into other large-scale transformations in the NHS [24,25]. Waiting times for the first contact were not significantly different in year two, but fell significantly in year three. Patients seemed appropriately triaged into identified care pathways, with more severe cases in the Getting More Help pathway compared to Getting Help where the interventions were also shorter in duration. Third sector partners were also providing increasing numbers of low-intensity interventions.

The majority of staff were positive about the vision of the transformation, and willing to expend considerable effort to see it work, but communication and staffing emerged as barriers to transformation, alongside challenges in recruitment and staff turnover. Staffing shortages potentially provide impetus for partnership working to expand the workforce.

There are only a limited number of previously published studies examining broad changes to community-based child mental health services. Although implementation research has identified promising strategies to improve services including: enhanced engagement to retain families in services [26]; improved training and support for evidence-based practices [27]; and expanded measurement and feedback systems to monitor services in real time, actual evaluation data remains limited [28]. The only studies identified in the last decade that have examined broad system change to improve demand and capacity in child and adolescent mental health services have included studies on the positive impact of introducing a ‘Choice and Partnership’ Approach. These services conduct an initial appointment to reach a shared understanding of patient and family needs with a range of options offered following the meeting [29-31]. Another study evaluated ‘Shared care mental health care’ (with primary care) [32] demonstrating how this model increases access to care as well as decreasing demand on services and a final study of integrated behavioural health care into primary health care systems showed some positive improvements in symptoms [33]. There are therefore some broad similarities with the current ‘transformation’ of CAMHS in England with a focus on integration and better shared decision-making.

There have been a number of evaluations of youth mental health service change for youth aged up to 25 years, in particular of the Australian headspace initiative [34-37]. Although relevant, the target age range is different. Numerous studies describe specific interventions introduced into child mental health systems, including: family check-up [38]; wraparound services for serious emotional disturbance [39]; parenting interventions [40]; development of interim services whilst awaiting mental health services [41]; free counselling support [42]; telephone-based treatments [43]; assertive outreach teams [44]; and early intervention in psychosis services [45,46].

A few articles have been published on the recent, broader system changes in the UK, primarily on the introduction of the Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) changes [47]. These are changes that have preceded the current CAMHS transformation, and have focused on ensuring that there are both more CAMHS practitioners and that these practitioners are trained to deliver evidence-based psychological therapies to child and adolescent populations [48]. The studies reporting on these changes do share similar findings on operational difficulties, the need for stakeholder involvement and the importance of leadership, although actual service-related measures, such as in this study, have not been reported [49,50]. The current CAMHS transformation has been described in some publications [51] with qualitative work conducted on key stakeholders [52], although some concerns raised that insufficient young people and parents have been included [53]. Quantitative data on the impact on access to services and efficiency in newly ‘transformed’ CAMHS service delivery has not been identified in any published studies to date- reflecting the recency of these changes. This study is therefore a timely evaluation of CAMHS provision in the context of transformation.

Strengths of this study include the use of data across one large NHS Foundation Trust, with different services, there was a consistent recording system, increasing the comparability of the data. Untreated mental health conditions negatively impact on development throughout the life course, making access to ‘adolescent-responsive’ and high-quality health systems crucially important [54] and the need to think about bringing services together in more integrated pathways of care [55] as well as finding ways to prioritise the student voice in how these services are organized [56].

Limitations

Limitations of the study include the timing of the analysis as the qualitative research was retrospective in Bucks. As this study is a snapshot in time, the changes taking place are ongoing and subject to flux. We were also unable to draw on sufficient Routine Outcome Measures to comment on the overall effectiveness of the transformation (because insufficient numbers were available to analyse) and we did not interview staff who had left the service. For the estimates of impact, we applied techniques appropriate to the non-experimental design, but could not entirely eliminate the potential for residual confounding [57]. We were also limited in the number of available comparator groups; with a greater number of CAMHS as controls, other techniques such as synthetic matching would permit matching on outcomes in the pre-period [58]. Finally, the intervention took place in a relatively affluent part of England, raising questions as to the extent to which results can be extrapolated to other CAMHS.

Conclusions

There is pressure to improve child and adolescent mental health services across many nations. Our findings provide robust evidence on how major service changes to child mental health services can be evaluated. Such service evaluations are rarely conducted and published because of the complexity of the intervention considered. This study highlights how the model of service change or ‘transformation’ adopted across many English services can help to increase access to services, but it takes time for the benefits of reorganisation to be realised.

Location and demographic characteristics of the study setting.

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Clnical Commissioning Group (CCG) funding allocated to Buckinghamshire and Oxfordshire CAMHS.

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Detailed quantitative results.

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10 Dec 2020

Submitted filename: Responses to the reviewer comments-resubmission 101220.docx

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1 Feb 2021

PONE-D-20-38869

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

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In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

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Reviewer #1: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript. Ways to evaluate the impact of changes in health services have not been fully addressed in the literature, so this article could make important contribution to the field. However, before it gets published, I would like to suggest authors address following comments, especially the way they organized the introduction and presented the results, to increase the likelihood of having meaningful contribution to the field.

Overall suggestions:

1. Please define the terms used in the manuscript clearly. For example, how authors define “access to service”? Similar issues with “delivery pathway”, “tiered service”, and “third sector partners”. For readers who are not familiar with services in UK. It would be helpful to know the definitions of these terms.

2. Please check acronyms (e.g., CAHMS, SPA, CCG) used in the manuscript, including figures and tables, to make sure they are spelled out and explained what they mean the first time they show up, and then use acronyms thoroughly afterwards. For example, CAMHS was first spelled out in p.4 instead of p.3. Authors sometime used the full name again after the acronyms has been introduced (e.g., line 325, p.15).

3. Please use terms consistently throughout the manuscript. For example, children and young people (CYP) or adolescent? Main analysis or primary analysis?

INTRODUCTION

Overall, the links between each paragraph in the introduction were not clear, and the justification of conducting this study was not clearly elaborated. Authors described the aim of this study in the end of the third paragraph. However, the overall knowledge gap was not clearly described and summarized, so the justification of conducting this study was not very compelling in the introduction. I suggest authors reorganize the introduction to summarize the knowledge gap in a more comprehensive way, and make the link between the knowledge gap and the aim of this study more explicit. Questions regarding each paragraph were listed below:

1) In the 1st paragraph, authors described that major changes have been taking place in the organizations of mental health services, the cost and prevalence related to mental health in UK, but I was left wondering what the current unmet needs were or what the service gap looked like in UK.

2) The 2nd paragraph included concerns across high-income nations regarding adequacy of healthcare services and listed recommendations regarding how services should meet the needs of the most vulnerable. However, it was unclear to me how these concerns and recommendation were linked to the mental health services specifically. If authors tried to use this paragraph to highlight the importance of improving access, they need to make it more explicit for readers.

3) The 3rd paragraph talked about many CAMHS transferred from traditional tiered model to integrated service informed by the THRIVE model. However, it was unclear to me what existing challenges with the traditional tiered model were, how changing to integrated services could address current unmet needs, and why authors wanted to highlight THRIVE model specifically? Was it the most commonly used model across services? Please clarify.

4) The 4th paragraph talked about the evaluation of impacts and implementation of changes remained limited, the government had recommendations to ‘transform’ services, and there was significant investment in local Transformation Plans. It was unclear to me what the main idea of this paragraph was. What unmet needs caused the government to argue there’s a need to transform service? What exactly did the local transformation plans look like, and how long have these plans been implemented? What problems would exist if we didn’t evaluate impacts of changes?

5) The 5th paragraph talked about several strategies to improve services. However, it was unclear what authors’ interpretations regarding previous literature were and how these previous findings were linked to this study.

6) The 6th paragraph talked about a WHO review highlighted the importance of improving mental services and having consistent way to collect and report data. However, I don’t see how the main idea of this paragraph was connected to other paragraphs in the introduction. I would suggest authors to move it to the discussion (e.g., line 335-337, p.15).

METHODS

1. Study setting: Please provide more background information about how service transformations were taking place in Bucks and Oxon. For example, when the transformation started in each area? What were the goals of transformation in each area? Possible reasons why these two areas had service transformations while other areas did not?

2. Overall, there was not enough detail regarding qualitative data and analysis. Authors only listed types of qualitative data they collected, including observations and interviews with stakeholders. It would be helpful for readers to know the focus of observations and guiding questions they had for interviews. In addition, there was only one sentence about data analysis, which did not provide enough information for readers to evaluate the rigor of the data analysis process.

3. Line 155-159, p.7: It would be helpful for readers to see the strengths of having a mixed methods design if authors could provide several examples to elaborate how they integrated QN and QL data to achieve a more complete overall interpretation.

RESULTS

1. As authors described in the method section, there were 5 research questions. It would be easier for readers to follow if authors could consider revising the sub-headings of the result section to make the link between results and each research question more explicit. Across different parts of the result section, there were two main issues needed to be further addressed, as described below:

1) First, sometimes it was unclear for readers to see how the findings were well supported by what kinds of data. For example, in p.7, authors summarize that Bucks and Oxon had similar core components of transformation, but as a reader, it was unclear to me whether these findings were supported by any of the QN or QL data authors collected. Similarly, in p.8-9, authors described that the introduction of the SPA was perceived by staff as the core change of the CAMHS transformation, but it was unclear to me whether this finding was supported by interviews with staff OR it was supported by observations OR both. Authors also described the numbers of people accessing SPA climbed quickly without providing related data to support this finding.

2) Second, the service transformations were taking place in both Bucks and Oxon. However, sometimes authors only described findings of one area and did not provide further explanations regarding another. I understand that these two areas started service transformations at different time, so it makes sense that some findings can only be illustrated by data of Bucks. However, I still think authors should at least have several sentences to address this issue as a whole, maybe in the method section or in the beginning of the result section to act as an orientation for readers. In addition, in the facilitators and barriers section, it was also unclear to me whether the findings were support by data of two areas or only by data of one area.

2. Other suggestions:

1) Line 241-242, p.11: It seems that the “tension” is an important finding, since authors decided to have it in the abstract and the discussion. I suggest authors provide more data to support this finding.

2) P. 11-12: The findings regarding facilitators did not seem robust because the statements were not clearly supported by data.

3) P.14, table 1: Regarding the waiting time, it seemed that it increased in year 1, and then decreased in year 3. Was there any other data could provide further explanations?

DISCUSSION

Similar to the suggestion above, I suggest authors reconsider the structure of the discussion section to make it more aligned with the research questions they proposed. In addition, the discussion lacked of citing relevant literature to demonstrate how the findings of this study fit with existing knowledge and what new insights they contribute.

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Reviewer #1: No

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1 Mar 2021

These are included, in detail, in the cover letter

Submitted filename: Response to Reviewers - PONE-D-20-38869R1.docx

Click here for additional data file.

8 Apr 2021

PONE-D-20-38869R1

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

PLOS ONE

Dear Dr. Fazel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

The original reviewer points out something that needs to be further addressed. Please take careful consideration on these comments.

==============================

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Chung-Ying Lin

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, although there are still several concerns needed to be addressed, the authors have made significant improvement regarding the clarity of the manuscript. The introduction and results are now more cohesive and focused compared to the previous version. They also added enough details to the method section.

Introduction:

p. 3 (Line 54-56): The first sentence of the introduction had some grammatical errors and included multiple ideas. I suggest the authors use more than one sentence to clearly articulate the ideas they want to convey, which would also be more reader-friendly.

p.3 (line 71-72): grammatical errors

Results:

p.13 (line 287-289): I have pointed out last time that the findings regarding facilitators did not seem robust because the statements were not clearly supported by data. However, the authors did not address this comment, and the statement “Staff showed determination…for transformation” is still not supported by any data, either from observations or interviews. Please revise.

Discussion:

I have pointed out last time that the discussion lacked of citing relevant literature to demonstrate how the findings of this study were similar or different from other work in the field of research. In the first paragraph, the authors summarized the overall findings of this study and only compared the findings with two other large-scale transformations in the NHS. In the second paragraph, the authors summarized the barriers to transformation, but did not compare the findings with any other studies. Overall, I still think the discussion section needs more work. How their findings are similar or different from other studies focusing on health service transformation? How the transformations they observed in UK are similar or different from other countries? Please elaborate and provide more details.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

9 Apr 2021

This text is also included in the Cover Letter attached.

PONE-D-20-38869R1

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

Dear Dr Lin,

Thank you very much for asking us to revise this manuscript and are grateful for the additional time Reviewer 1 has put into this work. We have tried to now address the final points raised and in summary are grateful for the opportunity to expand the discussion and contextualise the findings. We agree this is important, it has been partially address in our original submission (many, many moons ago) and at that point the reviewers seem to suggest these were not pertinent to our arguments and so we are delighted to have been able to update and reintroduce the broader literature for the reader. We have also addressed the request for additional evidence from qualitative interviews in the results section.

We would of course be happy to consider any further changes, and look forward to hearing from you.

Yours sincerely,

Mina Fazel (on behalf of the authors)

Detailed Response to Reviewers comments:

Reviewer #1: Overall, although there are still several concerns needed to be addressed, the authors have made significant improvement regarding the clarity of the manuscript. The introduction and results are now more cohesive and focused compared to the previous version. They also added enough details to the method section.

Thank you for these reassuring comments.

Introduction:

p. 3 (Line 54-56): The first sentence of the introduction had some grammatical errors and included multiple ideas. I suggest the authors use more than one sentence to clearly articulate the ideas they want to convey, which would also be more reader-friendly.

Done. This has now been changed and reads as follows:

There is heightened interest across many countries as to how mental health services can best meet the needs of their child and adolescent populations[1, 2]. The rising number of young people presenting with mental health needs is propelling services, across a number of nations, to introduce broad systemic changes.

p.3 (line 71-72): grammatical errors

Done. We hope the following has now corrected these errors:

The new model tries to enable all the agencies that are involved in a young person’s life to work together in a coherent and integrated manner

Results:

p.13 (line 287-289): I have pointed out last time that the findings regarding facilitators did not seem robust because the statements were not clearly supported by data. However, the authors did not address this comment, and the statement “Staff showed determination…for transformation” is still not supported by any data, either from observations or interviews. Please revise.

Done. Many apologies for not addressing this before. We have now added the following to this section:

Staff showed determination to deliver services aligned with the new vision for transformation, and although there were many changes that they had to manage, many described support for the overall programme of work:

“My instinct was, it was the right model with the right language with good principles and good thinking behind it and some evidence” (Staff Interview).

They agreed with the overall vision:

“I think it's creative. I think it's much more kind of proactive…there is a lot more emphasis on trying to work in the community and the proactive kind of looking at the early signs to really try and support our colleagues…in more preventative type kind of measures.” (Staff Interview)

Furthermore, staff demonstrated their commitment to the SPA with statements such as:

“it's just much more of a friendly front door to the service. (Staff Interview)

“…you can ring in at any time and you can just be reopened. You don't need a letter. You don't need a form. You don't need anybody else to do it for you. I think that's a big plus.” (Staff Interview)

“We are meant to do two days a week in SPA, but because we've had so many calls…If somebody else is on it and I know they're inundated, I'll say 'I'll do some of them'…And definitely probably work an extra hour at least each day, and don't take a lunch.” (Staff interview)

Discussion:

I have pointed out last time that the discussion lacked of citing relevant literature to demonstrate how the findings of this study were similar or different from other work in the field of research. In the first paragraph, the authors summarized the overall findings of this study and only compared the findings with two other large-scale transformations in the NHS. In the second paragraph, the authors summarized the barriers to transformation, but did not compare the findings with any other studies. Overall, I still think the discussion section needs more work. How their findings are similar or different from other studies focusing on health service transformation? How the transformations they observed in UK are similar or different from other countries? Please elaborate and provide more details.

Done. We have tried to provide greater context to the landscape of service changes for children’s mental health and also report on studies from the current CAMHS transformation. We hope this addresses the identified need in the discussion, with which we agree. We have also had to add 28 new references. The following three paragraphs are now entirely new:

There are only a limited number of previously published studies examining broad changes to community-based child mental health services. Although implementation research has identified promising strategies to improve services including: enhanced engagement to retain families in services [26]; improved training and support for evidence-based practices [27]; and expanded measurement and feedback systems to monitor services in real time, actual evaluation data remains limited [28]. The only studies identified in the last decade that have examined broad system change to improve demand and capacity in child and adolescent mental health services have included studies on the positive impact of introducing a ‘Choice and Partnership’ Approach. These services conduct an initial appointment to reach a shared understanding of patient and family needs with a range of options offered following the meeting [29-31]. Another study evaluated ‘Shared care mental health care’ (with primary care) [32] demonstrating how this model increases access to care as well as decreasing demand on services and a final study of integrated behavioural health care into primary health care systems showed some positive improvements in symptoms [33]. There are therefore some broad similarities with the current ‘transformation’ of CAMHS in England with a focus on integration and better shared decision-making.

There have been a number of evaluations of youth mental health service change for youth aged up to 25 years, in particular of the Australian headspace initiative [34-37]. Although relevant, the target age range is different. Numerous studies describe specific interventions introduced into child mental health systems, including: family check-up [38]; wraparound services for serious emotional disturbance [39]; parenting interventions [40]; development of interim services whilst awaiting mental health services [41]; free counselling support [42]; telephone-based treatments [43]; assertive outreach teams [44]; and early intervention in psychosis services [45, 46].

A few articles have been published on the recent, broader system changes in the UK, primarily on the introduction of the Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) changes [47]. These are changes that have preceded the current CAMHS transformation, and have focused on ensuring that there are both more CAMHS practitioners and that these practitioners are trained to deliver evidence-based psychological therapies to child and adolescent populations [48]. The studies reporting on these changes do share similar findings on operational difficulties, the need for stakeholder involvement and the importance of leadership, although actual service-related measures, such as in this study, have not been reported [49, 50]. The current CAMHS transformation has been described in some publications [51] with qualitative work conducted on key stakeholders [52], although some concerns raised that insufficient young people and parents have been included [53]. Quantitative data on the impact on access to services and efficiency in newly ‘transformed’ CAMHS service delivery has not been identified in any published studies to date- reflecting the recency of these changes. This study is therefore a timely evaluation of CAMHS provision in the context of transformation.

13 Apr 2021

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

PONE-D-20-38869R2

Dear Dr. Fazel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Chung-Ying Lin

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for all the hard efforts and I feel that you have done a good job!

Reviewers' comments:

23 Apr 2021

PONE-D-20-38869R2

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

Dear Dr. Fazel:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Chung-Ying Lin

Academic Editor

PLOS ONE